Diabetes Prevention & Management

Please fill out the following form to learn if you are a candidate for this program. Once we have received your form, we will contact you within 2-3 business days to discuss your eligibility. There is no commitment to attend the course until you are approved and you choose to register.

First name*

Last name*

Email*

Phone (Example +15632078932) *

Date of birth*

Month

Day

Year

Have you been diagnosed with or tested for abnormal fasting glucose levels?*

Yes

Unsure

If tested, what was your most recent fasting glucose level?*

Below 100 mg/dL

100–125 mg/dL (Pre-Diabetes)

126 mg/dL or higher (Diabetes)

Unsure

If tested, what was your most recent A1C level?*

Below 5.7%

5.7%–6.4% (Pre-Diabetes)

6.5% or higher (Diabetes)

Unsure

Have you been diagnosed with any of the following conditions? (Check all that apply)*

Pre-Diabetes

Diabetes

Hypertension (High Blood Pressure)

High Cholesterol

Obesity

Metabolic Syndrome

Cardiovascular Disease

PCOS (Polycystic Ovary Syndrome)

Thyroid Disorders

Autoimmune Disorders (e.g. Lupus, Rheumatoid Arthritis)

Kidney Disease

Liver Disease (e.g. Fatty Liver, Cirrhosis)

Other

Please list any medications and supplements you are currently taking: *

Do you have a primary care provider? If yes, please include the name of your provider.*

Do you have any additional health concerns or conditions that may affect your participation? If yes, please describe.*

Do you have some level of mobility that allows you to participate in light physical activity?*

Yes

Do you have access to a phone, tablet, or computer for virtual check-ins during Weeks 7–10?*

Yes

This program requires attending weekly sessions, making lifestyle changes, and tracking key health metrics (e.g., blood glucose). Are you willing to commit to these requirements?*

Yes

What motivates you to join this program?*

What do you hope to learn or achieve in this 11-week program?*

Initials*

I declare that the info I’ve provided is accurate and complete.

Phone (563) 207-8932

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